A pregnant client admitted to the labor room arrived with a fetal ...

[Caiter2013]

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client states that her water broke before coming to the hospital.
 
  The most appropriate nursing action would be to: 1. Sit the client in a high Fowler's position.
  2. Call the pharmacy for a tocolytic medication.
  3. Get intravenous (IV) therapy equipment and solution from the storage area.
  4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

Question 2

The nurse has collected the following data on a client in labor: the fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds.
 
  Using this information, the nurse should take which most appro-priate action? 1. Prepare for imminent delivery.
  2. Continue to monitor the client.
  3. Report the findings to the obstetrician.
  4. Report the FHR to the anesthesiologist on call.

[skipfourms123]

Answer to Question 1

4

Rationale: When an umbilical cord is protruding, the cord must be protected from drying out and from becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help ac-complish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims position. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.

Answer to Question 2

2

Rationale: The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 120 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR.

[Caiter2013]

Gracias!

[kthug]

TYSM